Time- limit amount of exposure Distance - don't stand close to pt shielding- use lead shields during procedures
Independant nursing Actions
dont require a Dr's order. Ex. removing a blanket for a pt with fever
Dependant nursing Actions
Dr's order required. Ex. giving meds, IV flushes
Collaborative Nursing Action
Involves several aspects of nursing. Ex. pt discharged to a nursing home with oxygen and a walker.- involves Dr, PT, Resp, Social worker.
evidence based practice
using findings from research, quality improvement and pt assessments in combination with clinical expertise and pt preferences, values in clinical decision making
S-subjective O-objective A-assessments P-plan I-implementation E- evaluation
SOAPIE is used with ____
POMR's (problem oriented medical records)
A-assessment D-diagnosis(nursing) P-planning I-implementation/ intervention E-Evaluation
When you first meet the patient. ABC's and neuro checks
Focused Assessment ( secondary)
change of shift, do a quick assessment while getting report
must be measurable, ex. seen, heard, felt or measured by another person.
SOLER ( for communicating with patients)
S-Sit quietly facing pt O-open posture (no crossed arms) L-Lean forward toward them E- eye contact R- relax
Chx: of pain (acute)
mild to severe , affects SNS, increased pulses, increased respirations, increased BP, restlessness, anxiousness, diaphoretic, py reports pain, crying, splinting, rubbing area
Chx: of pain (chronic)
mild to severe, affects PNS, v/s normal, skin is dry, pt depressed, withdrawn, doesnt mention pain unless asked, abscence of pain behaviors
due to damage of normal tissue or has the potential to do so.
comes from bones, joints, muscles, skin or connective tissue
Pain in abdomen, cranium, thorax
least amount of pain stimulation a person requires in order to feel pain
How much pain the pt can take
P-pain location Q-quality of pain R-radiates? S-severity of pain T-time/duration of pain
health promotion, immunizations, early detection and treatment
emergency care, diagnosis and treatment, acute care
long term care, care of the dying, rehab
IPPA inspect, palpate, percuss, auscultate. except abdomen- IAPP inspect, aucultate, percuss, palpate
pt says " i have pain"
what you see, discoloration of skin, increased lab values
3 stages of Selyes Adaption
Alarm, resistance, Exhaustion
Alarm stage of Selye
alerts the body's defenses
Resistance stage of Selye
body's adaption takes place, body attempts to cope with stress
Exhaustion stage of Selye
body can no longer remain in resistance. either goes back to normal and relaxes or death occurs
tendency of body to maintain a state of balance or equilibrium, while continually changing
body changes to stay in homeostasis, to achieve a balance between demands and resources
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